Primary CaretakerLegally and financially responsibleName(Required) First Last Primary Phone(Required)Alt PhoneEmail(Required) OccupationBilling Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary CaretakerName First Last Primary PhoneAlt PhoneEmail OccupationWhich of the phone numbers that you provided would you like us to call first?Emergency contact name:Emergency contact phone:Regarding payments, we accept: Visa Mastercard Discover American Express Cash Scratchpay Only local checks are allowed at this time- Isabella, Mercantile, 5/3, Huntington, and Independent. Checks are only allowed for good standing patients.How did you become aware of our hospital? Hospital sign Website Internet Other Personal recommendation Whom may we thank?*In admitting my pet(s) for diagnostics, treatment or surgery, I authorize the veterinarians of Healthy Acres Vet and their support staff, to administer such treatment and/or perform such diagnostics or surgical procedures as deemed medically necessary.If you would like to opt out of photos of your pet being used for promotion, social media, etc, please initial:*It is understood that an estimate of charges will be offered for services. Further, I realize that this is an estimate and there may be additional fees due to unforeseen changes in the treatment plan. I understand that I will be contacted, if possible, if there are any changes needed. Payment is due when services are renderedPrimary Caretaker's Signature(Required)Date(Required) MM slash DD slash YYYY Thank You for giving the Healthy Acres Veterinary Clinic the opportunity to care for your pet(s).Pet(s) InformationPet 1Name(Required)DOB or age(Required)Species(Required)Sex(Required)Color(Required)Neutered or spayed(Required) Yes No Not sure Please list any other veterinarians where your pet has been seen and how we can contact them for records:Has your pet ever bitten anyone?(Required) Yes No Not sure Has your pet ever had a vaccine reaction?(Required) Yes No Not sure Is your pet on a prescription food?(Required) Yes No If so, which oneWhat prior illness or surgery should we know about?(Required)Pet 2NameDOB or ageSpeciesSexColorNeutered or spayed Yes No Not sure Please list any other veterinarians where your pet has been seen and how we can contact them for records:Has your pet ever bitten anyone? Yes No Not sure Has your pet ever had a vaccine reaction? Yes No Not sure Is your pet on a prescription food? Yes No If so, which oneWhat prior illness or surgery should we know about?Pet 3NameDOB or ageSpeciesSexColorNeutered or spayed Yes No Not sure Please list any other veterinarians where your pet has been seen and how we can contact them for records:Has your pet ever bitten anyone? Yes No Not sure Has your pet ever had a vaccine reaction? Yes No Not sure Is your pet on a prescription food? Yes No If so, which oneWhat prior illness or surgery should we know about?PhoneThis field is for validation purposes and should be left unchanged.
